New tools to improve flu vaccination coverage in patients with risk factors

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Arce-Salinas, Y.N. Esquivel-Torruco, A.A. Bejarano-Juvera, A.K. Bustamante-Flores, N. Aguilar-Martínez, J.G. Azcorra-López, B. Cabañas-Espinosa, E.M. Luna-Rivera, A. Hernández-Alarcón, J. Reyna Figueroa" "autores" => array:10 [ 0 => array:2 [ "nombre" => "C.A." "apellidos" => "Arce-Salinas" ] 1 => array:2 [ "nombre" => "Y.N." "apellidos" => "Esquivel-Torruco" ] 2 => array:2 [ "nombre" => "A.A." "apellidos" => "Bejarano-Juvera" ] 3 => array:2 [ "nombre" => "A.K." "apellidos" => "Bustamante-Flores" ] 4 => array:2 [ "nombre" => "N." "apellidos" => "Aguilar-Martínez" ] 5 => array:2 [ "nombre" => "J.G." "apellidos" => "Azcorra-López" ] 6 => array:2 [ "nombre" => "B." "apellidos" => "Cabañas-Espinosa" ] 7 => array:2 [ "nombre" => "E.M." "apellidos" => "Luna-Rivera" ] 8 => array:2 [ "nombre" => "A." "apellidos" => "Hernández-Alarcón" ] 9 => array:2 [ "nombre" => "J. 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Note: level of implementation refers to the percentage of centres where the measure is currently applied, regardless of how long this has been so. The quality of the implementation of the measure refers to the average score awarded by the respondents for how optimum its actual application was (where 10 is the maximum possible score). The colours of the figure correspond to the 3 blocks of areas identified in the survey, while the codes (letters and numbers) correspond to the 15 measures covered by the survey." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Esther Redondo, Néboa Zozaya, Vicente Martín, Javier Villaseca, Juan Luis López-Belmonte, Georgina Drago, Elena Jurío, Álvaro Hidalgo-Vega" "autores" => array:9 [ 0 => array:2 [ "nombre" => "Esther" "apellidos" => "Redondo" ] 1 => array:2 [ "nombre" => "Néboa" "apellidos" => "Zozaya" ] 2 => array:2 [ "nombre" => "Vicente" "apellidos" => "Martín" ] 3 => array:2 [ "nombre" => "Javier" "apellidos" => "Villaseca" ] 4 => array:2 [ "nombre" => "Juan Luis" "apellidos" => "López-Belmonte" ] 5 => array:2 [ "nombre" => "Georgina" "apellidos" => "Drago" ] 6 => array:2 [ "nombre" => "Elena" "apellidos" => "Jurío" ] 7 => array:2 [ "nombre" => "Álvaro" "apellidos" => "Hidalgo-Vega" ] 8 => array:1 [ "colaborador" => "Grupo de expertos Gripetool" ] ] ] ] ] 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"autoresLista" => "Mónica López Campos, Héctor Reinao Cegoñino, Juan Lorente Riverola, Ignacio García Ascaso, David Abad Hernández, Sandra Castejón Ramírez, Inés Teresa Bolsa Ferrer, Carmen Viñas Viamonte, Delia González-De La Cuesta" "autores" => array:9 [ 0 => array:4 [ "nombre" => "Mónica" "apellidos" => "López Campos" "email" => array:1 [ 0 => "monicalopezmd@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "af0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cr0005" ] ] ] 1 => array:3 [ "nombre" => "Héctor" "apellidos" => "Reinao Cegoñino" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "af0005" ] ] ] 2 => array:3 [ "nombre" => "Juan" "apellidos" => "Lorente Riverola" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "af0010" ] ] ] 3 => array:3 [ "nombre" => "Ignacio" "apellidos" => "García Ascaso" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "af0005" ] ] ] 4 => array:3 [ "nombre" => "David" "apellidos" => "Abad Hernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "af0005" ] ] ] 5 => array:3 [ "nombre" => "Sandra" "apellidos" => "Castejón Ramírez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "af0005" ] ] ] 6 => array:3 [ "nombre" => "Inés Teresa" "apellidos" => "Bolsa Ferrer" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "af0005" ] ] ] 7 => array:3 [ "nombre" => "Carmen" "apellidos" => "Viñas Viamonte" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "af0005" ] ] ] 8 => array:4 [ "nombre" => "Delia" "apellidos" => "González-De La Cuesta" "email" => array:1 [ 0 => "dgonzalezd@salud.aragon.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "af0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Centro de Salud Actur Norte, Calle Cineasta Carlos Saura, 20, 50018 Zaragoza, Spain" "etiqueta" => "a" "identificador" => "af0005" ] 1 => array:3 [ "entidad" => "Centro de Salud Amparo Poch (Actur Oeste), Calle Emilia Pardo Bazán S/N, 50018 Zaragoza, Spain" "etiqueta" => "b" "identificador" => "af0010" ] 2 => array:3 [ "entidad" => "Instituto de Investigación Sanitaria de Aragón, Hospital Universitario Miguel Servet, San Juan Bosco 13, 50009 Zaragoza, Spain" "etiqueta" => "c" "identificador" => "af0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cr0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author at: C/ Cineasta Carlos Saura, 20, 50018 Zaragoza, Spain." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nuevas herramientas para mejorar la cobertura de vacunación antigripal en los pacientes con factores de riesgo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "f0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 600 "Ancho" => 1305 "Tamanyo" => 72144 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "al0020" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Percentage of vaccinated individuals with coronary risk factors." ] ] ] "textoCompleto" => "IntroductionThe World Health Organisation (WHO) has identified children, pregnant women, people with chronic illnesses, and the elderly as being at high risk for complications due to influenza virus infection; they are particularly vulnerable and, therefore, vaccination against influenza is all the more imperative in these circumstances.<a class="elsevierStyleCrossRef" href="#bb0005">1</a>Influenza is a major public health problem, affecting 1 in 3 children and 1 in 10 adults. It has been implicated in 5 million mild clinical illnesses; 150 000 hospital admissions and 15–40 000 excess deaths every year.<a class="elsevierStyleCrossRef" href="#bb0010">2</a>,<a class="elsevierStyleCrossRef" href="#bb0015">3</a>Since 2012, the WHO has recommended that vaccination campaigns be carried out to cover the most vulnerable groups, with an optimal coverage of 75–95% of these populations.<a class="elsevierStyleCrossRef" href="#bb0020">4</a>,<a class="elsevierStyleCrossRef" href="#bb0025">5</a> In Europe, influenza vaccination coverage has decreased in recent years, falling to below 50% in 2014<a class="elsevierStyleCrossRef" href="#bb0030">6</a>; in the United States, vaccination is recommended for everyone over 16 months of age who do not have contraindications.<a class="elsevierStyleCrossRefs" href="#bb0035">7–9</a>In Europe, the latest available vaccination coverage data refer to the 2014–2015 season and reveal an average of 45.5% (range 1.0–76.3%) among the elderly; 24% (5–54.9%) in healthcare workers; 49.8% (21–71.8%) for chronically ill populations, and 23.6% (0.3–56.1%) in pregnant women. In other countries, vaccination is administered to the entire population as a whole. In Spain, it is given to all people over 65 years of age, in addition to at-risk groups.<a class="elsevierStyleCrossRef" href="#bb0050">10</a>,<a class="elsevierStyleCrossRef" href="#bb0055">11</a>There are difficult barriers to overcome in the field of influenza vaccination, as knowledge about the vaccine does not always guarantee that it will accepted.<a class="elsevierStyleCrossRef" href="#bb0030">6</a> It could be useful to provide additional information addressed to people studying healthcare, with the aim of mediating safety concerns and increasing social pressure to help improve uptake and vaccination rates in this population.<a class="elsevierStyleCrossRef" href="#bb0030">6</a>,<a class="elsevierStyleCrossRef" href="#bb0060">12</a>Numerous studies have been conducted to estimate vaccination coverage and there is evidence that it falls far short of the desired target.<a class="elsevierStyleCrossRefs" href="#bb0060">12–18</a> Activities promoting immunisation have also been proven to be effective. To improve these results, people's attitude and knowledge about the flu vaccine must be examined.<a class="elsevierStyleCrossRefs" href="#bb0070">14–20</a>Various methods, such as postal mail, e-mail, short message service to mobile phones (SMS), or personalised telephone calls, have been used to send informative documentation and possible vaccination appointments.<a class="elsevierStyleCrossRef" href="#bb0095">19</a>,<a class="elsevierStyleCrossRef" href="#bb0100">20</a>,<a class="elsevierStyleCrossRefs" href="#bb0110">22–24</a> Overall, they have been demonstrated to be effective in increasing coverage and, above all, they have an impact on achieving high user satisfaction.Since 2013, active promotion has been conducted in one of the study centres by means of letters sent to the home of users over the age of 65 or those with risk factors, including the Saludinforma application, as opposed to traditional recruitment by healthcare professionals. The objectives put forth are to evaluate the response to the automated letter as a method of recruiting patients in the flu vaccination campaign and adherence rates of the different risk groups, to analyse the coverage achieved in recent years, and quantify user satisfaction with this method, bringing scientific evidence closer to the population.Material and methodsDescriptive, observational study undertaken at two healthcare centres in Sector I of Zaragoza, Actur Norte (Centre 1) and Actur Oeste (Centre 2).A sample of 173 935 patients eligible for influenza vaccination (over the age of 65 or younger with risk factors as per the influenza vaccination protocol in Aragon) was calculated using the OMI-AP database (computer programme used in primary care SALUD, Aragon), 71 565 of whom had been vaccinated. Individuals vaccinated outside the vaccination campaign were excluded.We found a possible bias in that the OMI-AP database does not include patients from private mutual insurance companies, but given that in the health areas studied, the number of people with private insure accounts for a minuscule percentage, this does not interfere with the interpretation of the results.Data were collected on influenza vaccinations administered and patients with risk factors between 2011 and 2017. From 2013 onwards, Centre 1 began to notify patients over 65 years of age or with risk factors by post as part of a pilot project of the Aragonese Health System called SaludInforma. The letter contains the appointment (including date and time) to receive the flu vaccine. No personalised notification was sent at Centre 2; the usual information channels were used.In addition, a survey was conducted regarding people's general knowledge, degree of satisfaction, and the occurrence of adverse reactions to 1017 of the users vaccinated as part of the official influenza campaign between October 2017 and January 2018 at both healthcare centres. The survey inquired about the patient's opinion regarding the intervention provided by healthcare Centre 1 in the form of active recruitment via post and about knowledge of the vaccine.The data collected were analysed using the SPSS statistical package, using means and standard deviations for quantitative variables and frequencies and percentages for qualitative variables, and a statistical parametric hypothesis test was performed to assess which of these variables were significant. The level of significance assumed in all tests was 0.05.ResultsOn analysis of the sample, the most prevalent group was that of people aged over 65 years, followed in frequency by asthmatic and diabetic patients at both healthcare centres.Overall, across all patients studied, vaccination coverage at healthcare Centre 1 in 2011–2012 (prior to the introduction of the notification postcard) was 32.15%. At healthcare Centre 2 during the same period, we detected a coverage rate of 28.13%, with no significant differences when comparing the coverage rates of both healthcare centres. However, when comparing vaccination coverage between the 2 healthcare centres over the 2 years following the introduction of the 2013–2014 letter (coverage at healthcare Centre 1: 46.89%, coverage at healthcare Centre 2: 31.28%), we found significant differences (<a class="elsevierStyleCrossRef" href="#f0005">Fig. 1</a>). Similarly, if we compare vaccination coverage from 2011–2012 and 2013–2014 at Centre 1, we find significant differences.<elsevierMultimedia ident="f0005"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#t0005">Table 1</a> displays the results analysed by risk group: (See <a class="elsevierStyleCrossRef" href="#t0010">Table 2</a>.)<elsevierMultimedia ident="t0005"></elsevierMultimedia><elsevierMultimedia ident="t0010"></elsevierMultimedia>Among subjects under 65 years of age with risk factors, vaccination coverage increased from 16.29% to 30.03% at Site 1 and remained stable at Site 2. These trends proved similar when the data obtained in 2017 were analysed, with 31.87% of patients vaccinated at Centre 1 and 17.07% at Centre 2.Among patients with asthma, no differences were observed between Centre 1 and Centre 2 before the intervention was launched. Following inclusion in Centre 1, the number of vaccinated patients between 2013 and 2014 (post-intervention) at Centre 1 increased significantly, rising to 30.49% (P < 0.001). Differences were also noted between the 2 centres in 2013–2014, with 18.83% vaccinated at Centre 2 (P < 0.001). These rates have been maintained until 2017 (<a class="elsevierStyleCrossRef" href="#f0010">Fig. 2</a>). The same differences were evident among COPD patients.<elsevierMultimedia ident="f0010"></elsevierMultimedia>Vaccination coverage increased for patients over 65 years of age after receiving the postal appointment; the differences were significant.Among diabetic patients, there is a clear reversal of the vaccination trend in the centres subsequent to the introduction of the letter, achieving a coverage rate of 41.55% of vaccinated patients at the centre with patients recruited by post during the years 2013–2014 (<a class="elsevierStyleCrossRef" href="#f0015">Fig. 3</a>).<elsevierMultimedia ident="f0015"></elsevierMultimedia>In the group of obese patients analysed, no significant differences were evident between the centres pre- and post-intervention.As for individuals with coronary heart disease, vaccination coverage was initially higher at Centre 2, with no differences between the 2 centres during the years 2013–2014. However, upon analysis of vaccination coverage between the centres from 2013 to 2017, significant differences were apparent (<a class="elsevierStyleCrossRef" href="#f0020">Fig. 4</a>).<elsevierMultimedia ident="f0020"></elsevierMultimedia>Regarding pregnant patients, no differences were observed between centres. Vaccination coverage varied greatly from 1 year to the next, and the change cannot be attributed to the introduction of the letter. The trend over the years has been toward a gradual increase in the number of vaccinations at both healthcare centres.In the group of immunocompromised patients, no differences were observed between the 2 centres pre-intervention. However, in the years following the 2013–2014 intervention, we did detect differences (Centre 1: 47.57%, Centre 2: 18.18%, P < 0.001). In 2017, these differences become more pronounced, with vaccination coverage rates of 60% at Centre 1 compared to 26.23% at Centre 2.In the Centre 1 rows, the P-value resulting from comparing the centre with itself before and after implementing the intervention (2011–2012 vs. 2013–2014) is shown. In the Centre 2 rows, the P-value is shown for the comparison between the 2 centres in the period immediately after beginning the intervention (2013–2014).Satisfaction surveysA total of 1017 patients took part in the 2017 vaccination campaign.At Centre 1, 53% of the participants received information about the vaccination campaign by means of the automated letter. At Centre 2, the information was received equally between medical consultations (29%), nursing (29%), and other means, primarily television (28%).At Centre 1, 78.3% of participants were satisfied with the letter as a means of information, while 14.6% felt that other means could have provided them with more information. Of respondents, 70.3% were pleased that the letter automatically assigned the vaccination appointment as opposed to 20.8% who preferred to make the appointment or had to reschedule it.With respect to adverse reactions to the vaccine, 81.99% of the participants at both centres had no adverse reactions, whereas 6.79% said that they had experienced complications at some point of time.Concerning the belief that the flu vaccine can cause influenza disease, 18.70% of the respondents believed this to be the case, compared to 69.29% who did not believe this statement.DiscussionThe need for the influenza vaccination campaign and the use of active promotion methods as part of this campaign is undeniable. Flu, despite being one of the most widely studied diseases and whose pathogenic agent is one of the best known viruses, continues to entail significant morbi-mortality, which is largely concentrated among those individuals at greatest risk for developing complications.It is essential that strategies be designed to promote the use of the flu vaccine, given that it is one of the most effective preventive measures against this disease.<a class="elsevierStyleCrossRef" href="#bb0045">9</a> These strategies should be reviewed, updated, and optimised, with the aim of adapting them to reach the patient in the most efficient way possible. This study seeks to evaluate the ordinary letter containing an automatically generated appointment as a possible strategy to promote vaccination, proving it to be an effective option.In light of the results obtained, the implementation of the letter is a measure that has proven to be particularly effective in our setting among people with asthma, COPD, diabetes, coronary heart disease, and immunocompromised patients, although other external factors, such as the emergence of a pandemic such as the current one, increase vaccination coverage.In the specific case of people over 65 years of age in our study, the automatically generated letter has led to an increase in vaccination, with vaccination coverage higher than the European average, but still far from the desired objectives.<a class="elsevierStyleCrossRef" href="#bb0050">10</a>This is different among pregnant women and morbidly obese patients, as the letter failed to prove effective in these risk groups. While vaccination rates have been gradually increasing over time, it is possible that pregnant women are also informed by other means, e.g. at obstetric check-ups or through the media. We should reflect on this group, as we are below the European average despite the efforts that have been undertaken. One possible explanation in the case of obese patients in particular would be that these results are the result of the low compliance of this risk group with health promotion health interventions; healthcare personnel perceive a low degree of awareness of illness in this population group. Therefore, other methods should be sought to approach these at-risk groups.In terms of the evaluation of patient satisfaction with this new health promotion measure, one very positive aspect has been how well this action has been received, with patients being satisfied with the fact that they have received an appointment for vaccination. It is striking that a substantial percentage of patients believe that the vaccine is capable of causing influenza, which makes it necessary to reinforce health education by improving patients' knowledge as part of the vaccination campaign.One of the limitations of the study has to do with the collection of data from earlier years. The classification of immunosuppressed patients in the computer system used, “OMI-AP”, is performed by means of a coding (CIAP) that is less accurate than that of other diagnoses, not distinguishing the type of immunosuppression and including only one type of immunosuppression in the patients receiving a letter. This can make it difficult to interpret the results correctly.Numerous studies propose different recruitment systems such as in: Michigan,<a class="elsevierStyleCrossRef" href="#bb0100">20</a> where they increased influenza vaccination rates in adolescents via e-mail; Philadelphia,<a class="elsevierStyleCrossRef" href="#bb0105">21</a> an e-mail-based influenza vaccination campaign to university employees improved coverage. Other primary care settings have also been able to implement SMS-based vaccination reminders to improve completion of childhood primary immunisation, as suggested by studies in Guatemala<a class="elsevierStyleCrossRef" href="#bb0115">23</a>; in Castilla-León (Spain),<a class="elsevierStyleCrossRef" href="#bb0120">24</a> which concluded that SMS-based intervention is a promising and efficient strategy to promote healthy habits among the elderly.No studies have analysed postal mail as in the present study, although there are studies with common objectives to increase vaccination coverage, in which significant methods of low- (postal-SMS), medium- (personalised telephone calls), and high-intensity (home visits, facilitators) have been found to increase community demand for vaccination, improve access, and improve provider/system response.<a class="elsevierStyleCrossRef" href="#bb0065">13</a>In recent years, the implementation of innovative computerised medical record and user data management systems has revolutionised healthcare, speeding up processes and even lowering certain costs. This electronic support also makes it easier to collect patient data, which is recently being updated in the health centres under study. It would be interesting to include the costs derived from this intervention in subsequent studies, as well as to calculate the costs that could be avoided by this initiative, assessing the use of new electronic notification methods or telephone messaging.ConclusionsGiven the low vaccination coverage among patients at risk for complications from influenza, further interventions to promote immunisation are needed as part of vaccination campaigns.Sending a letter to individuals at risk for flu complications has proven to be a measure worth considering in order to increase vaccination coverage. Several variables can modify the results of vaccination coverage; hence, further studies are needed to establish a cause–effect relationship.Because of the importance of vaccination, it should be considered another alternative when implementing various measures that bring us closer to immunisation targets.Patients have been satisfied with this measure to promote vaccination, as well as with the inclusion of an automatic appointment as part of it.Ethical responsibilitiesThe project was approved by the Clinical Research Ethics Committee of Aragon (CEICA) with project code: PI17/0312.In all cases, appropriate coding and identification dissociation was performed in the database in order to properly maintain confidentiality with respect to patient information.The study was carried out in accordance with the ethical standards recognised by the Declaration of Helsinki, the Standards of Good Clinical Practice, and in compliance with current legislation and current Spanish legal regulations (Law 14/2007 on biomedical research and the Law on personal data protection).FundingThe current research has not rece4ived any specific funding from any public agency, the commercial sector, or non-profit bodies.Conflict of InterestsThe authors have no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1851284" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "as0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "as0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "as0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "as0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1609728" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1851283" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "as0025" "titulo" => "Fundamentos" ] 1 => array:2 [ "identificador" => "as0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "as0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "as0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1609729" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "s0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "s0010" "titulo" => "Material and methods" ] 6 => array:3 [ "identificador" => "s0015" "titulo" => "Results" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "s0020" "titulo" => "Satisfaction surveys" ] ] ] 7 => array:2 [ "identificador" => "s0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "s0030" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "s0035" "titulo" => "Ethical responsibilities" ] 10 => array:2 [ "identificador" => "s0040" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "s0045" "titulo" => "Conflict of Interests" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1609728" "palabras" => array:5 [ 0 => "Primary care" 1 => "Automated letter" 2 => "Risk factor" 3 => "Influenza" 4 => "Vaccination" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1609729" "palabras" => array:5 [ 0 => "atención primaria" 1 => "carta automatizada" 2 => "factor de riesgo" 3 => "gripe" 4 => "vacunación" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "BackgroundInfluenza vaccination is one of the main interventions to prevent the flu. This study evaluates the impact of automated letter as a method of capturing patients at risk in influenza vaccination campaigns between 2013 and 2017. MethodsThis is a descriptive observational study in Sector I Zaragoza. Data analysis with SPSS and Excel. We studied 173 935 patients (>65 years old or with a risk factor) between 2011 and 2017, comparing the type of catchment used for vaccination. Centre 1 uses postal mail compared to Centre 2 that uses regular information channels. ResultsSignificant differences were observed, with an increase in vaccination in Centre 1 compared to Centre 2 (Centre 1: 29.59%; Centre 2: 19.76%, p < 0.001). Significant differences are found when comparing the vaccination rates in Centre 1 pre-post-intervention (P < 0.001). These differences are also significant when analysing the risk groups: >65 years, asthmatics, patients with COPD, diabetics, and patients with coronary heart disease. 78.3% of the Centre 1's surveys considerade quate the patient catchment via postal mail. ConclusionsSending a letter to those patients at risk of severe complications from influenza is an effective measure to increase influenza vaccination in the primary care setting." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "as0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "as0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "as0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "as0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "FundamentosLa vacunación antigripal es una de las intervenciones principales para prevenir la gripe. Este estudio evalúa el impacto de la carta automatizada como método de captación de pacientes de riesgo en las campañas de vacunación de gripe entre 2013–2017. MétodosSe trata de un estudio observacional descriptivo, en Sector I Zaragoza. Análisis de los datos con SPSS y Excel. Se estudian 173,935 pacientes (>65 años o con factor de riesgo) entre 2011 y 2017, comparando el tipo de captación utilizada para la vacunación. Centro 1 utiliza correo postal para la captación activa de la población, frente a centro 2 que usa canales habituales de información. ResultadosSe observaron diferencias significativas, con aumento de vacunación en el centro 1 respecto al centro 2 (centro 1: 29,59%; centro 2: 19,76%, p < 0,001). Encontramos diferencias significativas al comparar los índices de vacunación en el centro 1 pre-post intervención (p < 0,001). Estas diferencias también son significativas al analizar los grupos de riesgo: >65 años, asmáticos, pacientes con EPOC, diabéticos y pacientes con enfermedad coronaria.El 78,3% de las encuestas del centro 1 consideran adecuada la medida de captación vía correo postal. Conclusionesel envío de una carta personalizada a aquellos pacientes con riesgo de complicaciones por gripe es una medida que en nuestro estudio aumenta considerablemente la vacunación antigripal en el ámbito de atención primaria." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "as0025" "titulo" => "Fundamentos" ] 1 => array:2 [ "identificador" => "as0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "as0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "as0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Mónica López Campos, Héctor Reinao Cegoñino, Juan Lorente Riverola, Ignacio García Ascaso, David Abad Hernández, Sandra Castejón Ramírez, Inés Teresa Bolsa Ferrer, Carmen Viñas Viamonte, Delia González-De La Cuesta. Nuevas herramientas para mejorar la cobertura de vacunación antigripal en los pacientes con factores de riesgo. Vacunas. 2022. https://doi.org/10.1016/j.vacun.2021.11.003" ] ] "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "f0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1235 "Ancho" => 2175 "Tamanyo" => 198611 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "al0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Evolution of the percentage of vaccinated people among the population at risk at both centres." ] ] 1 => array:8 [ "identificador" => "f0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 552 "Ancho" => 1305 "Tamanyo" => 58969 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "al0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Percentage of vaccinated individuals with the risk factor asthma." ] ] 2 => array:8 [ "identificador" => "f0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 569 "Ancho" => 1305 "Tamanyo" => 60919 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "al0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Percentage of vaccinated individuals with the risk factor diabetes mellitus." ] ] 3 => array:8 [ "identificador" => "f0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 600 "Ancho" => 1305 "Tamanyo" => 72144 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "al0020" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Percentage of vaccinated individuals with coronary risk factors." ] ] 4 => array:8 [ "identificador" => "t0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "al0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">➢All patients ≥ 65 years old</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="5" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">➢Individuals < 65 years of age with chronic illness</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chronic cardiovascular diseases (except HBP on its own) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chronic respiratory diseases (including asthma and COPD) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diabetes Mellitus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Immunosuppression (including HIV, drug-induced and asplenia) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Morbid obesity (BMI ≥ 40 in adults) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">➢Pregnant women in any trimestre of gestation</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "People studied at high risk for complications from influenza." ] ] 5 => array:8 [ "identificador" => "t0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "al0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"></th><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Prior to letter</th><th class="td-with-role" title="\n \t\t\t\t\ttable-head\n \t\t\t\t ; entry_with_role_colgroup " colspan="5" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Letter</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Risk factor \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2011 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2012 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2013 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2011 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2012 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2013 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2011 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2012 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">P-value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Over the age of 65 years</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48.00% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47.09% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">53.29% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48.00% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47.09% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">53.29% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48.00% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47.09% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40.67% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39.37% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42.12% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40.67% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39.37% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42.12% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40.67% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39.37% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Coronary heart disease</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.23% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28.43% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37.95% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.23% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28.43% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37.95% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.23% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28.43% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38.38% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32.37% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35.37% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38.38% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32.37% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">35.37% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38.38% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32.37% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.454 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">COPD</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33.33% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34.82% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38.10% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33.33% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34.82% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38.10% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33.33% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34.82% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.029 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34.09% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34.13% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36.36% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34.09% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34.13% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36.36% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34.09% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34.13% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.117 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Asthma</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.88% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.61% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29.57% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.88% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.61% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29.57% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.88% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.61% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.03% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.86% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17.93% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.03% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.86% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17.93% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.03% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.86% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BMI > 40</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.31% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.39% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.97% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.31% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.39% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.97% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.31% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.39% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.606 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.82% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.48% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.25% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.82% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.48% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.25% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.82% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.48% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.334 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diabetes</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23.36% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24.57% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39.70% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23.36% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24.57% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39.70% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23.36% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24.57% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.92% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29.52% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.89% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.92% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29.52% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.89% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.92% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29.52% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pregnancy</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.32% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.66% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.59% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.32% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.66% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.59% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.32% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.66% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.04% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.70% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.18% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.04% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.70% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.18% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.04% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.70% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.075 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inmunodepression</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19.35% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.81% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45.16% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19.35% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.81% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45.16% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19.35% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.81% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.004 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.29% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.33% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.41% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.29% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.33% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.41% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.29% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.33% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Vaccinated individuals at each centre by all risk factors." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bs0005" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bb0005" "etiqueta" => "1." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Strategies in recommending influenza vaccination in Europe and US" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Rizzo" 1 => "G. Rezza" 2 => "W. Ricciardi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1080/21645515.2017.1367463" "Revista" => array:7 [ "tituloSerie" => "Hum Vaccin Immunother." "fecha" => "2018" "volumen" => "14" "numero" => "3" "paginaInicial" => "693" "paginaFinal" => "698" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28922083" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bb0010" "etiqueta" => "2." "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Human influenza: One health, one world" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.B. Jernigan" 1 => "N.J. 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New tools to improve flu vaccination coverage in patients with risk factors

Nuevas herramientas para mejorar la cobertura de vacunación antigripal en los pacientes con factores de riesgo

Mónica López Camposa,

Corresponding author

monicalopezmd@hotmail.com

Corresponding author at: C/ Cineasta Carlos Saura, 20, 50018 Zaragoza, Spain.

, Héctor Reinao Cegoñinoa, Juan Lorente Riverolab, Ignacio García Ascasoa, David Abad Hernándeza, Sandra Castejón Ramíreza, Inés Teresa Bolsa Ferrera, Carmen Viñas Viamontea, Delia González-De La Cuestac

a Centro de Salud Actur Norte, Calle Cineasta Carlos Saura, 20, 50018 Zaragoza, Spain

b Centro de Salud Amparo Poch (Actur Oeste), Calle Emilia Pardo Bazán S/N, 50018 Zaragoza, Spain

c Instituto de Investigación Sanitaria de Aragón, Hospital Universitario Miguel Servet, San Juan Bosco 13, 50009 Zaragoza, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="s0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0065">Introduction</span><p id="p0005" class="elsevierStylePara elsevierViewall">The World Health Organisation &#40;WHO&#41; has identified children&#44; pregnant women&#44; people with chronic illnesses&#44; and the elderly as being at high risk for complications due to influenza virus infection&#59; they are particularly vulnerable and&#44; therefore&#44; vaccination against influenza is all the more imperative in these circumstances&#46;<a class="elsevierStyleCrossRef" href="#bb0005"><span class="elsevierStyleSup">1</span></a></p><p id="p0010" class="elsevierStylePara elsevierViewall">Influenza is a major public health problem&#44; affecting 1 in 3 children and 1 in 10 adults&#46; It has been implicated in 5 million mild clinical illnesses&#59; 150&#8239;000 hospital admissions and 15&#8211;40&#8239;000 excess deaths every year&#46;<a class="elsevierStyleCrossRef" href="#bb0010"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0015"><span class="elsevierStyleSup">3</span></a></p><p id="p0015" class="elsevierStylePara elsevierViewall">Since 2012&#44; the WHO has recommended that vaccination campaigns be carried out to cover the most vulnerable groups&#44; with an optimal coverage of 75&#8211;95&#37; of these populations&#46;<a class="elsevierStyleCrossRef" href="#bb0020"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0025"><span class="elsevierStyleSup">5</span></a> In Europe&#44; influenza vaccination coverage has decreased in recent years&#44; falling to below 50&#37; in 2014<a class="elsevierStyleCrossRef" href="#bb0030"><span class="elsevierStyleSup">6</span></a>&#59; in the United States&#44; vaccination is recommended for everyone over 16&#8239;months of age who do not have contraindications&#46;<a class="elsevierStyleCrossRefs" href="#bb0035"><span class="elsevierStyleSup">7&#8211;9</span></a></p><p id="p0020" class="elsevierStylePara elsevierViewall">In Europe&#44; the latest available vaccination coverage data refer to the 2014&#8211;2015 season and reveal an average of 45&#46;5&#37; &#40;range 1&#46;0&#8211;76&#46;3&#37;&#41; among the elderly&#59; 24&#37; &#40;5&#8211;54&#46;9&#37;&#41; in healthcare workers&#59; 49&#46;8&#37; &#40;21&#8211;71&#46;8&#37;&#41; for chronically ill populations&#44; and 23&#46;6&#37; &#40;0&#46;3&#8211;56&#46;1&#37;&#41; in pregnant women&#46; In other countries&#44; vaccination is administered to the entire population as a whole&#46; In Spain&#44; it is given to all people over 65&#8239;years of age&#44; in addition to at-risk groups&#46;<a class="elsevierStyleCrossRef" href="#bb0050"><span class="elsevierStyleSup">10</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0055"><span class="elsevierStyleSup">11</span></a></p><p id="p0025" class="elsevierStylePara elsevierViewall">There are difficult barriers to overcome in the field of influenza vaccination&#44; as knowledge about the vaccine does not always guarantee that it will accepted&#46;<a class="elsevierStyleCrossRef" href="#bb0030"><span class="elsevierStyleSup">6</span></a> It could be useful to provide additional information addressed to people studying healthcare&#44; with the aim of mediating safety concerns and increasing social pressure to help improve uptake and vaccination rates in this population&#46;<a class="elsevierStyleCrossRef" href="#bb0030"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0060"><span class="elsevierStyleSup">12</span></a></p><p id="p0030" class="elsevierStylePara elsevierViewall">Numerous studies have been conducted to estimate vaccination coverage and there is evidence that it falls far short of the desired target&#46;<a class="elsevierStyleCrossRefs" href="#bb0060"><span class="elsevierStyleSup">12&#8211;18</span></a> Activities promoting immunisation have also been proven to be effective&#46; To improve these results&#44; people&#39;s attitude and knowledge about the flu vaccine must be examined&#46;<a class="elsevierStyleCrossRefs" href="#bb0070"><span class="elsevierStyleSup">14&#8211;20</span></a></p><p id="p0035" class="elsevierStylePara elsevierViewall">Various methods&#44; such as postal mail&#44; e-mail&#44; short message service to mobile phones &#40;SMS&#41;&#44; or personalised telephone calls&#44; have been used to send informative documentation and possible vaccination appointments&#46;<a class="elsevierStyleCrossRef" href="#bb0095"><span class="elsevierStyleSup">19</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0100"><span class="elsevierStyleSup">20</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bb0110"><span class="elsevierStyleSup">22&#8211;24</span></a> Overall&#44; they have been demonstrated to be effective in increasing coverage and&#44; above all&#44; they have an impact on achieving high user satisfaction&#46;</p><p id="p0040" class="elsevierStylePara elsevierViewall">Since 2013&#44; active promotion has been conducted in one of the study centres by means of letters sent to the home of users over the age of 65 or those with risk factors&#44; including the <span class="elsevierStyleItalic">Saludinforma</span> application&#44; as opposed to traditional recruitment by healthcare professionals&#46; The objectives put forth are to evaluate the response to the automated letter as a method of recruiting patients in the flu vaccination campaign and adherence rates of the different risk groups&#44; to analyse the coverage achieved in recent years&#44; and quantify user satisfaction with this method&#44; bringing scientific evidence closer to the population&#46;</p></span><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0070">Material and methods</span><p id="p0045" class="elsevierStylePara elsevierViewall">Descriptive&#44; observational study undertaken at two healthcare centres in Sector I of Zaragoza&#44; Actur Norte &#40;Centre 1&#41; and Actur Oeste &#40;Centre 2&#41;&#46;</p><p id="p0050" class="elsevierStylePara elsevierViewall">A sample of 173&#8239;935 patients eligible for influenza vaccination &#40;over the age of 65 or younger with risk factors as per the influenza vaccination protocol in Aragon&#41; was calculated using the OMI-AP database &#40;computer programme used in primary care SALUD&#44; Aragon&#41;&#44; 71&#8239;565 of whom had been vaccinated&#46; Individuals vaccinated outside the vaccination campaign were excluded&#46;</p><p id="p0055" class="elsevierStylePara elsevierViewall">We found a possible bias in that the OMI-AP database does not include patients from private mutual insurance companies&#44; but given that in the health areas studied&#44; the number of people with private insure accounts for a minuscule percentage&#44; this does not interfere with the interpretation of the results&#46;</p><p id="p0060" class="elsevierStylePara elsevierViewall">Data were collected on influenza vaccinations administered and patients with risk factors between 2011 and 2017&#46; From 2013 onwards&#44; Centre 1 began to notify patients over 65&#8239;years of age or with risk factors by post as part of a pilot project of the Aragonese Health System called <span class="elsevierStyleItalic">SaludInforma</span>&#46; The letter contains the appointment &#40;including date and time&#41; to receive the flu vaccine&#46; No personalised notification was sent at Centre 2&#59; the usual information channels were used&#46;</p><p id="p0065" class="elsevierStylePara elsevierViewall">In addition&#44; a survey was conducted regarding people&#39;s general knowledge&#44; degree of satisfaction&#44; and the occurrence of adverse reactions to 1017 of the users vaccinated as part of the official influenza campaign between October 2017 and January 2018 at both healthcare centres&#46; The survey inquired about the patient&#39;s opinion regarding the intervention provided by healthcare Centre 1 in the form of active recruitment via post and about knowledge of the vaccine&#46;</p><p id="p0070" class="elsevierStylePara elsevierViewall">The data collected were analysed using the SPSS statistical package&#44; using means and standard deviations for quantitative variables and frequencies and percentages for qualitative variables&#44; and a statistical parametric hypothesis test was performed to assess which of these variables were significant&#46; The level of significance assumed in all tests was 0&#46;05&#46;</p></span><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0075">Results</span><p id="p0075" class="elsevierStylePara elsevierViewall">On analysis of the sample&#44; the most prevalent group was that of people aged over 65&#8239;years&#44; followed in frequency by asthmatic and diabetic patients at both healthcare centres&#46;</p><p id="p0080" class="elsevierStylePara elsevierViewall">Overall&#44; across all patients studied&#44; vaccination coverage at healthcare Centre 1 in 2011&#8211;2012 &#40;prior to the introduction of the notification postcard&#41; was 32&#46;15&#37;&#46; At healthcare Centre 2 during the same period&#44; we detected a coverage rate of 28&#46;13&#37;&#44; with no significant differences when comparing the coverage rates of both healthcare centres&#46; However&#44; when comparing vaccination coverage between the 2 healthcare centres over the 2&#8239;years following the introduction of the 2013&#8211;2014 letter &#40;coverage at healthcare Centre 1&#58; 46&#46;89&#37;&#44; coverage at healthcare Centre 2&#58; 31&#46;28&#37;&#41;&#44; we found significant differences &#40;<a class="elsevierStyleCrossRef" href="#f0005">Fig&#46; 1</a>&#41;&#46; Similarly&#44; if we compare vaccination coverage from 2011&#8211;2012 and 2013&#8211;2014 at Centre 1&#44; we find significant differences&#46;</p><elsevierMultimedia ident="f0005"></elsevierMultimedia><p id="p0085" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#t0005">Table 1</a> displays the results analysed by risk group&#58; &#40;See <a class="elsevierStyleCrossRef" href="#t0010">Table 2</a>&#46;&#41;</p><elsevierMultimedia ident="t0005"></elsevierMultimedia><elsevierMultimedia ident="t0010"></elsevierMultimedia><p id="p0090" class="elsevierStylePara elsevierViewall">Among subjects under 65&#8239;years of age with risk factors&#44; vaccination coverage increased from 16&#46;29&#37; to 30&#46;03&#37; at Site 1 and remained stable at Site 2&#46; These trends proved similar when the data obtained in 2017 were analysed&#44; with 31&#46;87&#37; of patients vaccinated at Centre 1 and 17&#46;07&#37; at Centre 2&#46;</p><p id="p0095" class="elsevierStylePara elsevierViewall">Among patients with asthma&#44; no differences were observed between Centre 1 and Centre 2 before the intervention was launched&#46; Following inclusion in Centre 1&#44; the number of vaccinated patients between 2013 and 2014 &#40;post-intervention&#41; at Centre 1 increased significantly&#44; rising to 30&#46;49&#37; &#40;P&#8239;&#60;&#8239;0&#46;001&#41;&#46; Differences were also noted between the 2 centres in 2013&#8211;2014&#44; with 18&#46;83&#37; vaccinated at Centre 2 &#40;P&#8239;&#60;&#8239;0&#46;001&#41;&#46; These rates have been maintained until 2017 &#40;<a class="elsevierStyleCrossRef" href="#f0010">Fig&#46; 2</a>&#41;&#46; The same differences were evident among COPD patients&#46;</p><elsevierMultimedia ident="f0010"></elsevierMultimedia><p id="p0100" class="elsevierStylePara elsevierViewall">Vaccination coverage increased for patients over 65&#8239;years of age after receiving the postal appointment&#59; the differences were significant&#46;</p><p id="p0105" class="elsevierStylePara elsevierViewall">Among diabetic patients&#44; there is a clear reversal of the vaccination trend in the centres subsequent to the introduction of the letter&#44; achieving a coverage rate of 41&#46;55&#37; of vaccinated patients at the centre with patients recruited by post during the years 2013&#8211;2014 &#40;<a class="elsevierStyleCrossRef" href="#f0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="f0015"></elsevierMultimedia><p id="p0110" class="elsevierStylePara elsevierViewall">In the group of obese patients analysed&#44; no significant differences were evident between the centres pre- and post-intervention&#46;</p><p id="p0115" class="elsevierStylePara elsevierViewall">As for individuals with coronary heart disease&#44; vaccination coverage was initially higher at Centre 2&#44; with no differences between the 2 centres during the years 2013&#8211;2014&#46; However&#44; upon analysis of vaccination coverage between the centres from 2013 to 2017&#44; significant differences were apparent &#40;<a class="elsevierStyleCrossRef" href="#f0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="f0020"></elsevierMultimedia><p id="p0120" class="elsevierStylePara elsevierViewall">Regarding pregnant patients&#44; no differences were observed between centres&#46; Vaccination coverage varied greatly from 1 year to the next&#44; and the change cannot be attributed to the introduction of the letter&#46; The trend over the years has been toward a gradual increase in the number of vaccinations at both healthcare centres&#46;</p><p id="p0125" class="elsevierStylePara elsevierViewall">In the group of immunocompromised patients&#44; no differences were observed between the 2 centres pre-intervention&#46; However&#44; in the years following the 2013&#8211;2014 intervention&#44; we did detect differences &#40;Centre 1&#58; 47&#46;57&#37;&#44; Centre 2&#58; 18&#46;18&#37;&#44; P&#8239;&#60;&#8239;0&#46;001&#41;&#46; In 2017&#44; these differences become more pronounced&#44; with vaccination coverage rates of 60&#37; at Centre 1 compared to 26&#46;23&#37; at Centre 2&#46;</p><p id="p0130" class="elsevierStylePara elsevierViewall">In the Centre 1 rows&#44; the P-value resulting from comparing the centre with itself before and after implementing the intervention &#40;2011&#8211;2012 vs&#46; 2013&#8211;2014&#41; is shown&#46; In the Centre 2 rows&#44; the P-value is shown for the comparison between the 2 centres in the period immediately after beginning the intervention &#40;2013&#8211;2014&#41;&#46;</p><span id="s0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0080">Satisfaction surveys</span><p id="p0135" class="elsevierStylePara elsevierViewall">A total of 1017 patients took part in the 2017 vaccination campaign&#46;</p><p id="p0140" class="elsevierStylePara elsevierViewall">At Centre 1&#44; 53&#37; of the participants received information about the vaccination campaign by means of the automated letter&#46; At Centre 2&#44; the information was received equally between medical consultations &#40;29&#37;&#41;&#44; nursing &#40;29&#37;&#41;&#44; and other means&#44; primarily television &#40;28&#37;&#41;&#46;</p><p id="p0145" class="elsevierStylePara elsevierViewall">At Centre 1&#44; 78&#46;3&#37; of participants were satisfied with the letter as a means of information&#44; while 14&#46;6&#37; felt that other means could have provided them with more information&#46; Of respondents&#44; 70&#46;3&#37; were pleased that the letter automatically assigned the vaccination appointment as opposed to 20&#46;8&#37; who preferred to make the appointment or had to reschedule it&#46;</p><p id="p0150" class="elsevierStylePara elsevierViewall">With respect to adverse reactions to the vaccine&#44; 81&#46;99&#37; of the participants at both centres had no adverse reactions&#44; whereas 6&#46;79&#37; said that they had experienced complications at some point of time&#46;</p><p id="p0155" class="elsevierStylePara elsevierViewall">Concerning the belief that the flu vaccine can cause influenza disease&#44; 18&#46;70&#37; of the respondents believed this to be the case&#44; compared to 69&#46;29&#37; who did not believe this statement&#46;</p></span></span><span id="s0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0085">Discussion</span><p id="p0160" class="elsevierStylePara elsevierViewall">The need for the influenza vaccination campaign and the use of active promotion methods as part of this campaign is undeniable&#46; Flu&#44; despite being one of the most widely studied diseases and whose pathogenic agent is one of the best known viruses&#44; continues to entail significant morbi-mortality&#44; which is largely concentrated among those individuals at greatest risk for developing complications&#46;</p><p id="p0165" class="elsevierStylePara elsevierViewall">It is essential that strategies be designed to promote the use of the flu vaccine&#44; given that it is one of the most effective preventive measures against this disease&#46;<a class="elsevierStyleCrossRef" href="#bb0045"><span class="elsevierStyleSup">9</span></a> These strategies should be reviewed&#44; updated&#44; and optimised&#44; with the aim of adapting them to reach the patient in the most efficient way possible&#46; This study seeks to evaluate the ordinary letter containing an automatically generated appointment as a possible strategy to promote vaccination&#44; proving it to be an effective option&#46;</p><p id="p0170" class="elsevierStylePara elsevierViewall">In light of the results obtained&#44; the implementation of the letter is a measure that has proven to be particularly effective in our setting among people with asthma&#44; COPD&#44; diabetes&#44; coronary heart disease&#44; and immunocompromised patients&#44; although other external factors&#44; such as the emergence of a pandemic such as the current one&#44; increase vaccination coverage&#46;</p><p id="p0175" class="elsevierStylePara elsevierViewall">In the specific case of people over 65&#8239;years of age in our study&#44; the automatically generated letter has led to an increase in vaccination&#44; with vaccination coverage higher than the European average&#44; but still far from the desired objectives&#46;<a class="elsevierStyleCrossRef" href="#bb0050"><span class="elsevierStyleSup">10</span></a></p><p id="p0180" class="elsevierStylePara elsevierViewall">This is different among pregnant women and morbidly obese patients&#44; as the letter failed to prove effective in these risk groups&#46; While vaccination rates have been gradually increasing over time&#44; it is possible that pregnant women are also informed by other means&#44; e&#46;g&#46; at obstetric check-ups or through the media&#46; We should reflect on this group&#44; as we are below the European average despite the efforts that have been undertaken&#46; One possible explanation in the case of obese patients in particular would be that these results are the result of the low compliance of this risk group with health promotion health interventions&#59; healthcare personnel perceive a low degree of awareness of illness in this population group&#46; Therefore&#44; other methods should be sought to approach these at-risk groups&#46;</p><p id="p0185" class="elsevierStylePara elsevierViewall">In terms of the evaluation of patient satisfaction with this new health promotion measure&#44; one very positive aspect has been how well this action has been received&#44; with patients being satisfied with the fact that they have received an appointment for vaccination&#46; It is striking that a substantial percentage of patients believe that the vaccine is capable of causing influenza&#44; which makes it necessary to reinforce health education by improving patients&#39; knowledge as part of the vaccination campaign&#46;</p><p id="p0190" class="elsevierStylePara elsevierViewall">One of the limitations of the study has to do with the collection of data from earlier years&#46; The classification of immunosuppressed patients in the computer system used&#44; &#8220;OMI-AP&#8221;&#44; is performed by means of a coding &#40;CIAP&#41; that is less accurate than that of other diagnoses&#44; not distinguishing the type of immunosuppression and including only one type of immunosuppression in the patients receiving a letter&#46; This can make it difficult to interpret the results correctly&#46;</p><p id="p0195" class="elsevierStylePara elsevierViewall">Numerous studies propose different recruitment systems such as in&#58; Michigan&#44;<a class="elsevierStyleCrossRef" href="#bb0100"><span class="elsevierStyleSup">20</span></a> where they increased influenza vaccination rates in adolescents via e-mail&#59; Philadelphia&#44;<a class="elsevierStyleCrossRef" href="#bb0105"><span class="elsevierStyleSup">21</span></a> an e-mail-based influenza vaccination campaign to university employees improved coverage&#46; Other primary care settings have also been able to implement SMS-based vaccination reminders to improve completion of childhood primary immunisation&#44; as suggested by studies in Guatemala<a class="elsevierStyleCrossRef" href="#bb0115"><span class="elsevierStyleSup">23</span></a>&#59; in Castilla-Le&#243;n &#40;Spain&#41;&#44;<a class="elsevierStyleCrossRef" href="#bb0120"><span class="elsevierStyleSup">24</span></a> which concluded that SMS-based intervention is a promising and efficient strategy to promote healthy habits among the elderly&#46;</p><p id="p0200" class="elsevierStylePara elsevierViewall">No studies have analysed postal mail as in the present study&#44; although there are studies with common objectives to increase vaccination coverage&#44; in which significant methods of low- &#40;postal-SMS&#41;&#44; medium- &#40;personalised telephone calls&#41;&#44; and high-intensity &#40;home visits&#44; facilitators&#41; have been found to increase community demand for vaccination&#44; improve access&#44; and improve provider&#47;system response&#46;<a class="elsevierStyleCrossRef" href="#bb0065"><span class="elsevierStyleSup">13</span></a></p><p id="p0205" class="elsevierStylePara elsevierViewall">In recent years&#44; the implementation of innovative computerised medical record and user data management systems has revolutionised healthcare&#44; speeding up processes and even lowering certain costs&#46; This electronic support also makes it easier to collect patient data&#44; which is recently being updated in the health centres under study&#46; It would be interesting to include the costs derived from this intervention in subsequent studies&#44; as well as to calculate the costs that could be avoided by this initiative&#44; assessing the use of new electronic notification methods or telephone messaging&#46;</p></span><span id="s0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0090">Conclusions</span><p id="p0210" class="elsevierStylePara elsevierViewall">Given the low vaccination coverage among patients at risk for complications from influenza&#44; further interventions to promote immunisation are needed as part of vaccination campaigns&#46;</p><p id="p0215" class="elsevierStylePara elsevierViewall">Sending a letter to individuals at risk for flu complications has proven to be a measure worth considering in order to increase vaccination coverage&#46; Several variables can modify the results of vaccination coverage&#59; hence&#44; further studies are needed to establish a cause&#8211;effect relationship&#46;</p><p id="p0220" class="elsevierStylePara elsevierViewall">Because of the importance of vaccination&#44; it should be considered another alternative when implementing various measures that bring us closer to immunisation targets&#46;</p><p id="p0225" class="elsevierStylePara elsevierViewall">Patients have been satisfied with this measure to promote vaccination&#44; as well as with the inclusion of an automatic appointment as part of it&#46;</p></span><span id="s0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0095">Ethical responsibilities</span><p id="p0230" class="elsevierStylePara elsevierViewall">The project was approved by the Clinical Research Ethics Committee of Aragon &#40;CEICA&#41; with project code&#58; PI17&#47;0312&#46;</p><p id="p0235" class="elsevierStylePara elsevierViewall">In all cases&#44; appropriate coding and identification dissociation was performed in the database in order to properly maintain confidentiality with respect to patient information&#46;</p><p id="p0240" class="elsevierStylePara elsevierViewall">The study was carried out in accordance with the ethical standards recognised by the Declaration of Helsinki&#44; the Standards of Good Clinical Practice&#44; and in compliance with current legislation and current Spanish legal regulations &#40;Law 14&#47;2007 on biomedical research and the Law on personal data protection&#41;&#46;</p></span><span id="s0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0100">Funding</span><p id="p0245" class="elsevierStylePara elsevierViewall">The current research has not rece4ived any specific funding from any public agency&#44; the commercial sector&#44; or non-profit bodies&#46;</p></span><span id="s0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0105">Conflict of Interests</span><p id="p0250" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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        "resumen" => "<span id="as0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0010">Background</span><p id="sp0035" class="elsevierStyleSimplePara elsevierViewall">Influenza vaccination is one of the main interventions to prevent the flu&#46; This study evaluates the impact of automated letter as a method of capturing patients at risk in influenza vaccination campaigns between 2013 and 2017&#46;</p></span> <span id="as0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0015">Methods</span><p id="sp0040" class="elsevierStyleSimplePara elsevierViewall">This is a descriptive observational study in Sector I Zaragoza&#46; Data analysis with SPSS and Excel&#46; We studied 173&#8239;935 patients &#40;&#62;<span class="elsevierStyleHsp" style=""></span>65&#8239;years old or with a risk factor&#41; between 2011 and 2017&#44; comparing the type of catchment used for vaccination&#46; Centre 1 uses postal mail compared to Centre 2 that uses regular information channels&#46;</p></span> <span id="as0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0020">Results</span><p id="sp0045" class="elsevierStyleSimplePara elsevierViewall">Significant differences were observed&#44; with an increase in vaccination in Centre 1 compared to Centre 2 &#40;Centre 1&#58; 29&#46;59&#37;&#59; Centre 2&#58; 19&#46;76&#37;&#44; p&#8239;&#60;&#8239;0&#46;001&#41;&#46; Significant differences are found when comparing the vaccination rates in Centre 1 pre-post-intervention &#40;P&#8239;&#60;&#8239;0&#46;001&#41;&#46; These differences are also significant when analysing the risk groups&#58; &#62;<span class="elsevierStyleHsp" style=""></span>65 years&#44; asthmatics&#44; patients with COPD&#44; diabetics&#44; and patients with coronary heart disease&#46; 78&#46;3&#37; of the Centre 1&#39;s surveys considerade quate the patient catchment via postal mail&#46;</p></span> <span id="as0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0025">Conclusions</span><p id="sp0050" class="elsevierStyleSimplePara elsevierViewall">Sending a letter to those patients at risk of severe complications from influenza is an effective measure to increase influenza vaccination in the primary care setting&#46;</p></span>"
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        "resumen" => "<span id="as0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0035">Fundamentos</span><p id="sp0055" class="elsevierStyleSimplePara elsevierViewall">La vacunaci&#243;n antigripal es una de las intervenciones principales para prevenir la gripe&#46; Este estudio eval&#250;a el impacto de la carta automatizada como m&#233;todo de captaci&#243;n de pacientes de riesgo en las campa&#241;as de vacunaci&#243;n de gripe entre 2013&#8211;2017&#46;</p></span> <span id="as0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0040">M&#233;todos</span><p id="sp0060" class="elsevierStyleSimplePara elsevierViewall">Se trata de un estudio observacional descriptivo&#44; en Sector I Zaragoza&#46; An&#225;lisis de los datos con SPSS y Excel&#46; Se estudian 173&#44;935 pacientes &#40;&#62;<span class="elsevierStyleHsp" style=""></span>65 a&#241;os o con factor de riesgo&#41; entre 2011 y 2017&#44; comparando el tipo de captaci&#243;n utilizada para la vacunaci&#243;n&#46; Centro 1 utiliza correo postal para la captaci&#243;n activa de la poblaci&#243;n&#44; frente a centro 2 que usa canales habituales de informaci&#243;n&#46;</p></span> <span id="as0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0045">Resultados</span><p id="sp0065" class="elsevierStyleSimplePara elsevierViewall">Se observaron diferencias significativas&#44; con aumento de vacunaci&#243;n en el centro 1 respecto al centro 2 &#40;centro 1&#58; 29&#44;59&#37;&#59; centro 2&#58; 19&#44;76&#37;&#44; p&#8239;&#60;&#8239;0&#44;001&#41;&#46; Encontramos diferencias significativas al comparar los &#237;ndices de vacunaci&#243;n en el centro 1 pre-post intervenci&#243;n &#40;p&#8239;&#60;&#8239;0&#44;001&#41;&#46; Estas diferencias tambi&#233;n son significativas al analizar los grupos de riesgo&#58; &#62;<span class="elsevierStyleHsp" style=""></span>65 a&#241;os&#44; asm&#225;ticos&#44; pacientes con EPOC&#44; diab&#233;ticos y pacientes con enfermedad coronaria&#46;</p><p id="sp0070" class="elsevierStyleSimplePara elsevierViewall">El 78&#44;3&#37; de las encuestas del centro 1 consideran adecuada la medida de captaci&#243;n v&#237;a correo postal&#46;</p></span> <span id="as0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0050">Conclusiones</span><p id="sp0075" class="elsevierStyleSimplePara elsevierViewall">el env&#237;o de una carta personalizada a aquellos pacientes con riesgo de complicaciones por gripe es una medida que en nuestro estudio aumenta considerablemente la vacunaci&#243;n antigripal en el &#225;mbito de atenci&#243;n primaria&#46;</p></span>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#10146;All patients &#8805;&#8239;65&#8239;years old</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="5" align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#10146;Individuals &#60;&#8239;65&#8239;years of age with chronic illness</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic cardiovascular diseases &#40;except HBP on its own&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic respiratory diseases &#40;including asthma and COPD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diabetes Mellitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Immunosuppression &#40;including HIV&#44; drug-induced and asplenia&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Morbid obesity &#40;BMI&#8239;&#8805;&#8239;40 in adults&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#10146;Pregnant women in any trimestre of gestation</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="sp0025" class="elsevierStyleSimplePara elsevierViewall">People studied at high risk for complications from influenza&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "t0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "al0030"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col"></th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="2" align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Prior to letter</th><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_colgroup " colspan="5" align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Letter</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Risk factor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">P-value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Over the age of 65&#8239;years</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&#46;00&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&#46;09&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53&#46;29&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&#46;00&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&#46;09&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53&#46;29&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&#46;00&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&#46;09&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&#46;67&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#46;37&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&#46;12&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&#46;67&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#46;37&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&#46;12&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&#46;67&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39&#46;37&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Coronary heart disease</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;23&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#46;43&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#46;95&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;23&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#46;43&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#46;95&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;23&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&#46;43&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#46;38&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#46;37&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#46;37&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#46;38&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#46;37&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#46;37&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#46;38&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32&#46;37&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;454&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">COPD</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&#46;33&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#46;82&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#46;10&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&#46;33&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&#46;82&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&#46;10&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33&#46;33&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Diabetes</td><td class="td" title="\n
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                  \t\t\t\t ; entry_with_role_rowgroup " rowspan="2" align="" valign="\n
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                  \t\t\t\t">Pregnancy</td><td class="td" title="\n
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Article information

ISSN: 24451460
Original language: English

DOI:10.1016/j.vacune.2022.07.009

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